President’s Emergency Plan for AIDS Relief Updated Gender Strategy lays out “Who, Why, What and How” of Gender and HIV, while gaps highlight divide between plan and practice

The President’s Emergency Plan for AIDS Relief Updated Gender Strategy begins with a notice of a new requirement, made prominent with upper-case letters, underlined and printed in red, not unlike a warning: “Note that there is a new PEPFAR requirement to undertake a gender analysis related to HIV at the country-level by March 2016.”

Perhaps it is a warning. The requirement lays out a formidable challenge with high-stakes goals, asking in-country inter-agency teams to identify gender related issues that affect access to HIV-related resources and services and control over those resources, and bring about “differences in power among and between women and men, girls and boys.” The analysis, by the strategy’s definition of “Who benefits from gender integration in HIV programs” will look at roles and norms affecting girls, women, boys, men, gay, disabled and transgender people, men who have sex with men, and people who sell sex. Information for the analysis will be gathered with the input of government and local civil society organizations, existing data as well as data gathered specifically for that purpose, and “should go beyond the health sector to describe broad structural issues within a country, as well as U.S. government investments in other sectors . . .”

All of this is aimed at better integrating HIV services through the “PEPFAR Gender Framework,” a plan that brings its own formidable challenges. The framework calls for identifying the populations that should be targeted, “according to the epidemiological profile of the country.” But when being a member of a specific population, or participating in activities that makes one a member, is illegal in a country –as it is for men who have sex with men, transgendered individuals and sex workers — or makes one invisible — as being a child, disabled, or gay can in some countries, epidemiological profiles can be compromised. The input of civil society organizations comprised of and representing marginalized populations also has been challenged by the very structural issues the analysis seeks to identify, in the past. It is a challenge that can expect to increase in Nigeria, where a new anti-gay law makes meeting with organizations representing gay people punishable by imprisonment. It is a challenge that would have added problems for men who have sex with men in Uganda under the law that country’s lawmakers passed defining “aggravated homosexuality” as having HIV while gay, and proposed life in prison as punishment.

The document addresses its Mobius Strip of built-in “Catch 22,” challenges, noting that securing “meaningful participation” of all of the groups that need to be included in the planning, evaluation, and benefits of PEPFAR programs will mean “finding innovative ways to solicit feedback from marginalized groups, addressing barriers that may impact on beneficiaries ability to speak candidly, and establishing confidential and responsive mechanisms.”

The benefits of the analysis, the document points out, have the potential to accrue to virtually everyone in a country impacted by HIV. That includes women and girls, who are affected by norms and inequalities that have led in some countries to HIV prevalence that averages three times higher among young women than young men. It includes men and boys, affected by expectations that lead to risks, as well as lower rates of testing and treatment. It includes men who have sex with men among whom HIV rates are likely to be 19 times higher than those among men in the general population, the document says. It includes transgender women, with an estimated likelihood 48 times greater than that of the general population, to get HIV.